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Program Integrity Unit

Staff in the Program Integrity Unit (PI) monitor financial claims for NH's Medicaid plan. PI reviews all provider claims for fraud, waste or abuse. The unit also recovers overpayments. If there appears to be a case of fraud, it is referred to the Attorney General's office for further review. PI also conducts reviews to determine if recipients are inappropriately using certain types of medications.

PI provides management of the Quality Improvement Organization (QIO) contract, which is responsible for the review of all hospital admissions for medical necessity and quality of care.

Specifics activities include:

  • On-site audits and desk reviews of provider bills and medical records;
  • Monitor the Quality Inpatient Organization Contract for in-patient claims;
  • Review of pended provider claims;
  • Verification of recipient medical services;
  • Monitor provider sanctions received by Medical Boards;
  • Make recommendations for claims processing system modifications;
  • Assess and report on program outcomes and recommend policy and procedure changes as necessary; and
  • Review of new provider enrollment applications as necessary.
  • NH Medicaid Provider Exclusion and Sanction List
    The New Hampshire Medicaid program wants to ensure that the best medical professionals participate in the Medicaid program. When the program finds good reason that a provider should no longer be eligible to participate, they are placed on a list of terminated providers. To access this list, click on the link below, and read the disclaimer regarding the list of terminations.

    List of Terminations Microsoft Excel Symbol
    A complete list of providers who have had their enrollment in the New Hampshire Medicaid program terminated since 4/01/2013 and the reasons for the termination. Please note that not all providers who have had their enrollment terminated since 4/01/2013 are on the list. The New Hampshire Medicaid Program Integrity Unit, rather, terminated the providers on the list for conduct which was deemed potentially detrimental to the New Hampshire Medicaid program. This list is reviewed monthly for updates.

    Medicaid providers are reminded that utilizing this list does not replace the requirement to complete the following database searches:

  • Office of Inspector General Exclusion Database
  • System for Award Management

 

Fingerprint-based Criminal Background Check (FCBC)
The Affordable Care Act requires, as a component of provider screening, that certain providers and those with a 5% or more direct or indirect ownership interest in them be considered high risk for fraudulent billing activities and accordingly, be required to undergo a national and state criminal background check, including fingerprinting. (42 U.S.C. 1396a(a)(77); 42 U.S.C. 1396a(kk) and 42 CFR Part 455 Subpart E.) FCBC requirements are set forth in Administrative rule He-W 520. For more information on how this process works please view the PowerPoint presentation and the frequently asked questions (FAQ).

 

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New Hampshire Department of Health and Human Services
129 Pleasant Street | Concord, NH | 03301-3852


copyright 2016. State of New Hampshire